UK: Ageing Population

Baroness Jolly Excerpts

Tuesday 19th March 2013 Lords Chamber

[Earl Howe]

My Lords, I very much agree with the noble Baroness. It is our ambition that people should receive high-quality, integrated, person-centred services that deliver the best outcomes to the service user. Making the service as a whole more efficient is the other benefit of integrating service. There is no single definitive model of integration. Some localities are further advanced than others in thinking about new ways of delivering it. We are developing the concept of pioneers to support the rapid dissemination and uptake of lessons learnt across the country, but we want to encourage local experimentation as much as we can to allow local areas to provide integrated care at scale and pace.

[Baroness Jolly]

My Lords, there are several common themes between the report from the noble Lord, Lord Filkin, and his group, and that of the scrutiny committee of the draft Care and Support Bill, which was published today. One of those themes is the funding of personal care, which has to be shared between the individual and the state. As recommended by the Dilnot commission, will the Government invest in an awareness campaign to inform people of this situation and the importance of planning ahead?

[Earl Howe]

I am sure my noble friend is right that there is a job of work to do to inform people about the new arrangements that we are bringing in to implement the Dilnot recommendations. My right honourable friend the Chancellor’s announcement at the weekend confirms that we will introduce a cap on care costs and extend the means test upper capital threshold at the earlier date than previously announced, namely on April 2016. The reason for the change in date is to bring it into line with changes to single-tier pensions. We will need to disseminate this information sooner than we would otherwise have done.

NHS: Mid Staffordshire NHS Foundation Trust

Baroness Jolly Excerpts

Monday 11th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I, too, thank the noble Lord, Lord Patel, for bringing this important issue to the attention of this House, and for so eloquently outlining all the areas of concern shared by all noble Lords.

The negligent treatment of patients at the Mid Staffordshire hospital is inexcusable. To an extent, we are all culpable, as we let a culture develop across the NHS that fails to keep the patient central. I know that, as noble Lords have said, this is not the same everywhere, but there are certainly quarters in some hospitals where one can identify this still. We are now obliged to build a system to prevent its repetition. Given the time restrictions, I will limit my comments to a specific viewpoint. I am taking the perspective of the patient.

Our systems should be more proactive in seeking out patient perspectives and more responsive in addressing their complaints. At Mid Staffs, the patients were speaking out about the abusive environment and many warning signs were apparent, yet no one was listening, these signs went unnoticed and any criticism was oppressed. Not only was the abuse suffered intolerable but it is unacceptable that this inquiry would not have happened without significant public pressure over several years. The inability of the hospital and the Government to act swiftly when presented with these conditions of appalling care must be reflected upon.

Putting patients and their needs at the core of our health service is one step that we can take towards correcting this. Many changes need to take place. We must stop designing our patient safety systems on what fits well with our institutions. Instead, the core of how we protect patients should be built around the patients themselves. Three areas of focus are needed to make this happen.

We need to ensure that patients, families and carers are empowered to speak out when they receive negligent care. I support the swift adoption of the recommendations to create an accessible complaints system. I note the point made by the noble Lord, Lord Turnberg, that we should not need a complaints system, and I hope to goodness that we will soon be in a position in which we will not need one, but until that time I believe that we do. Every patient should know how they can have a voice and should be secure in knowing that there will be recourse for any problems that they raise. I ask my noble friend the Minister to commit to a complaints system that is responsive and responsible, that all patients are aware of, and where complaints are thoroughly investigated and will be received by the board. Will the Minister confirm that such a system could be implemented anywhere that NHS money is spent: private, not-for-profit and NHS trusts alike?

Patients should automatically be given all information regarding the level of care that they have received, including information about any lapses in the quality of care or mistakes made. I therefore welcome the recommendation of the establishment of a statutory duty of candour. Health workers, be they senior consultants or junior nursing assistants, must feel that they can talk with their patients if something goes wrong. This creates an open dialogue between patients and their carers and ensures that mistakes are addressed in an open, well informed manner. Will the Minister confirm that there will be a statutory duty of candour?

In addition, patient organisations must be listened to and action taken. Local Healthwatches should use the tools they have been given to work on behalf of patients to make sure that negligent care is caught early and corrected. They need to ensure that Healthwatch England and the CQC are informed immediately where systemic abuse and intolerable care are identified.

Even if every one of the 290 Francis recommendations were to be instituted immediately, a more fundamental culture change must happen throughout health and social care facilities. Noble Lords have already referred to this cultural issue. Solutions, as seen through the perspective of patients themselves, should be core to the strategy. Through efforts to give patients information about their care, empowering them to speak out and then listening to their voice, we will be able to help prevent these tragedies in care repeating themselves.

Care Services: Elderly People

Baroness Jolly Excerpts

Wednesday 6th March 2013 Grand Committee

[Baroness Jolly]

My Lords, I start by thanking the noble Lord, Lord Turnberg, for bringing this important issue to the attention of this Committee. He has adequately covered areas of the economy, so I shall leave that. Care in the community is a critical component of our current health system and an even more critical component of our future health system, and we must ensure continued support for those who require and provide this vital service.

Today I wish to touch on a few distinct aspects of this issue. First, I want to highlight the growing demand for care in the community for the elderly population. As we are all certainly aware, the elderly population are particularly vulnerable to conditions that require long-term care which, if left untreated, can lead to a revolving door of hospital care for the elderly, which is both unhealthy and costly. Building on this, I want to draw attention to the ways in which the newly established clinical commissioning groups can work to improve the quality of care in the community as well as to encourage the use of this type of care. Finally, I will pose three questions to the Minister that reflect my concerns and hopes for the future of care in the community for elderly individuals.

Older people already represent the largest cohort of patients in the NHS, accounting for 60% of hospital admissions. Hospital days are dangerous for elderly people and expensive. Patients are susceptible to infections in the ward and often fail to eat properly while staying in the hospital. Moreover, these stays can encourage a loss of independence, which leads to added problems on discharge. Home healthcare is proven to deliver better outcomes for patients. There is evidence that it can lead to lower costs and reduce admissions to hospital. Home-based models of care have proven to be effective for patients with multiple diagnoses and comorbidities with a high risk of hospitalisation. According to Department of Health statistics, during September and October 2011 some 128,517 hospital bed days were lost as the result of the delayed discharge of people who could have been cared for in the community had the right support had been available.

In order to provide care in the community that is of the same quality as a hospital environment, CCGs must ensure collaboration between acute care, community care and social care. This was clearly called for in the Health and Social Care Act 2012, and we expect CCGs and local authorities to be actively pursuing this practice. It is particularly important for elderly patients as long-term conditions associated with old age are particularly complex to treat and often involve several different types of health and social care intervention. These services are provided over months and years by a range of organisations in the public, private and voluntary sectors, and it is hard to split them into single episodes. Pathway design is a critical and urgent task for CCGs to engage in.

In order to delay acute care for our elderly citizens, we must also refocus our energy on prevention. Joint strategic needs assessments must emphasise the value of preventive care for the elderly, including simple things: measures to decrease falls, improve nutrition to prevent diabetes and encourage community-based programmes such as Dementia Friends. Here the involvement of the voluntary sector can often be critical.

Part of the prevention agenda is about combating loneliness. Isolation is associated with poor physical and mental health in older people, both conditions that undermine the health we seek to provide our citizens. Local providers work together to address this issue and must not fall short in this critical area of care, because it is care. Social isolation affects about 1 million older people and has a severe impact on people’s quality of life in old age. Mentoring projects, befriending schemes and computer classes form part of a solution built to engage an elderly population in their community.

The patient must be at the centre of every health and care system we create. The location and community in which we choose to spend our later years deeply affects our quality of life. By supporting people to remain in their homes for as long as they wish, we provide an invaluable service to those patients we serve. In light of these remarks, I ask the Minister to confirm the following three expectations that relate to CCGs. CCGs will be expected to work alongside local authorities on integrated care pathways for the older population in the community, which might or might not involve shared budgets. CCGs will be expected to enhance preventive services in the community to reduce unnecessary hospitalisations. They will also be expected to embrace a campaign against isolation in the community, working with local authorities, especially among the elderly who wish to stay in their homes.

Health and Social Care Act

Baroness Jolly Excerpts

Tuesday 5th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I thank my noble friend for meeting Members from these Benches on this issue nearly two weeks ago. Will he confirm for the House that, in line with assurances given during the course of the Bill last year, the regulations will promote integration of services in the best interest of patients?

[Earl Howe]

I think that everybody was agreed during the passage of the Health and Social Care Bill that we wish to encourage integration in the way that services are commissioned. Integration in this context should be taken as a term that reflects the experience of the patient. The patient has to feel that he or she is on a seamless pathway of care. That care may be provided by a number of agencies, if necessary, whether in the NHS or social care, but the patient’s experience should not be disjointed. Therefore, as my noble friend will remember, numerous provisions were inserted into what is now the Act to ensure that commissioning should be on that basis. Nothing in these regulations interferes with that, but it is very much in our minds to make it crystal clear that integration of services is one of the main factors which commissioners should take into account.

NHS: Healthcare UK

Baroness Jolly Excerpts

Thursday 14th February 2013 Lords Chamber

[Earl Howe]

I am sure the noble Lord will know that a number of our flagship hospitals already have private facilities which treat domestic and international private patients, including Great Ormond Street and the Royal Marsden. All such treatment of course takes place outside NHS provision. However, it is important to emphasise that Healthcare UK is about much more than private patients. In fact, that will not be its primary focus. It is about sharing this country’s expertise, technology and knowledge to support healthcare systems and infrastructure with international partners. Healthcare UK will provide support if there are NHS organisations wanting to bring patients in from overseas but that will not be its principal focus.

[Baroness Jolly]

My Lords, the NHS brand is the envy of the world and we welcome this enterprise. Will my noble friend tell me how many clinicians he expects might be involved and in what particular roles and disciplines?

[Earl Howe]

It is a little too early to say because the business plan for Healthcare UK has yet to be drawn up. We have appointed a managing director in the shape of Howard Lyons who I think will do an excellent job. It remains to be seen what requirements are needed. We are looking at certain target markets at the moment—in particular, the Middle East, the United Arab Emirates, Saudi Arabia, Libya, China and India. But it depends on the requests that we get from those countries as to what skills set might be needed.

NHS: Private Companies

Baroness Jolly Excerpts

Monday 11th February 2013 Lords Chamber

[Earl Howe]

My Lords, the Government’s policy is that competition should never be deployed for competition’s sake but only in the interests of patients. Furthermore, competition should be on the basis of quality and not price. The answer to the noble Lord’s question is that we need to arrive progressively at a system of tariffs that fairly reflect the value and cost of the work that providers do, and that all providers should compete equally on that basis.

[Baroness Jolly]

My Lords, Parts 3 and 4 of the Health and Social Care Act were rigorously debated. Will my noble friend confirm that the regulations covering this will be laid down soon, as 1 April is less than two months away?

[Earl Howe]

I can tell my noble friend that the Government intend to lay these regulations shortly.

Social Care Funding

Baroness Jolly Excerpts

Monday 11th February 2013 Lords Chamber

[Earl Howe]

My Lords, I thank the noble Lord. I am with him in spirit. I say that because not only do I believe in cross-party consensus on a matter as important as this, but I hope he will accept from me that the way we have tried to structure this package, taking the cap and the means test in combination, has precisely been to target those of more modest means. Currently only those with assets of less than £23,250 and a low income receive help from the state with their care costs. Our changes will mean that those with property value and savings of £100,000 or less in 2010 prices will start to receive financial support. That means that the most support will go to those in greatest need. I am advised that had we, for example, opted for a higher means-test threshold, it would not in practice have brought into the net that many more people. We felt that the fairest way of cutting the cake was to try to concentrate the benefit on those of lowest means while also removing the fear of catastrophic care costs from everybody in the system.

[Baroness Jolly]

My Lords, we on these Benches are delighted that the Government decided to implement the principles of the Dilnot report. The care and support Bill places a duty on local authorities to provide information and advice. In addition, there will be a need to set up some sort of taxi-metering system in order to achieve that outcome. Has the Minister any idea about how that might be achieved?

[Earl Howe]

My noble friend is absolutely right. One of the tasks that faces us over the next two or three years is to ensure that every member of the public has easy access to information which enables them to make plans and take decisions about their own or their family’s future. We will therefore be working very closely with local authorities on that front. It is important that there are websites. My department is already devoting a section of its website to appropriate information on this front. More generally, we need to ensure that the system is not only fair to people, but clear to people.

NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012

Baroness Jolly Excerpts

Tuesday 5th February 2013 Lords Chamber

[Lord Warner]

My Lords, I support the points made by my two noble friends in their eloquent speeches. I speak as someone who was given assurances about campaigning on Report by the noble Baroness, Lady Northover. My filing system is not up to discovering whether she sent me a letter, but I have no recollection that she withdrew her assurances in any way. The set of regulations in Regulation 36(1) and (2) of Part 6, taken together, totally neuter the ability of local Healthwatch organisations to campaign effectively.

As my noble friend said, the extraordinary thing is that the Government have chosen, with absolutely brilliant timing, to bring this before the House on the day before publication of the Francis report. My noble friend was wise. He did not know when the Francis report was coming out, but the Government had an opportunity to offer the chance to defer these regulations. It is very odd that we are having this debate when no doubt tomorrow there will be an unleashing—a positive avalanche—of rhetoric about the need to put the patient at the centre of the NHS. There was a warm-up on “Newsnight” yesterday. We can see it coming. Now we have a set of regulations that will set up local Healthwatch alongside Healthwatch England. The organisations will be totally unable to campaign against policies that they regard as not in patients’ interests.

I will spend a few moments on the text of the regulations. The Explanatory Note on page 38 of the regulations states:

“Regulation 36 sets out certain political activities which are not to be treated as carried out for the benefit of the community”.

This is an extraordinary statement, but Regulation 36(1) and (2) go rather wider than that. The Explanatory Note does not accurately reflect what is in the regulations. Consideration needs to be given to the quality of the drafting of either the Explanatory Note or of Regulation 36(1)(a) and (b), interrelated with Regulation 36(2). Regulation 36(1)(a) and (b) prevents a local Healthwatch organisation promoting or opposing changes in the policy adopted by any governmental or public body in relation to any matter, including the promotion of changes to the policy, unless under Regulation 36(2)(a) they can reasonably be regarded as incidental to other activities which are acceptable. So it is left to a multitude of small local social enterprises around the country to make a judgment, day by day, about whether what they are doing offends the provisions in Regulation 36(1)(a) and (b), as modified by Regulation 36(2)(a).

Even if we assume that there is some scope under that wording for them to campaign—which I very much doubt on any reasonable interpretation of the words—they will be in a state of uncertainty, and they will be expected to resolve that uncertainty with the minuscule amounts of money they have to carry out their operations. So if the Government want them to be effective with the small amounts of money there is likely to be, why do they want them to be tied-up by and concerned about obscure regulations which call into question their right to do the sane and sensible thing on behalf of patients in their area?

This House operates on the basis that one can accept assurances from government spokesmen while legislation is going through and we do not pursue matters when we are given them. However, as an individual Member of this House, I take umbrage about the assurances we were given on our ability to campaign. And not only me—the point about campaigning was repeated by my noble friend Lady Pitkeathley and again we were given assurances. We did not press this point further at Third Reading but, had we not been given those assurances, I am sure we would have come back to this issue at that stage. The Government have some explaining to do about why those assurances were not reflected in the wording of these regulations.

I support the point made by my noble friend Lord Collins about the extraordinary definition of a lay person. As other interests said to the Secondary Legislation Scrutiny Committee, this definition of lay person and lay involvement creates a situation in which it is possible to have people in local Healthwatch organisations who could be said to be in a position to manipulate discussion and debate on behalf of the very people that a local Healthwatch organisation is supposed to be monitoring and looking into.

Finally, I draw attention to the requirement provisions in Regulations 40 to 43. If one looks at these as a normal human being, they again pose a bureaucratic nightmare that will be excessively burdensome for the small organisations which will have to understand what it all means. I do not think it is beyond the wit of the Department of Health, Ministers and civil servants to produce proportionate regulations in relation to small bodies which spend relatively small amounts of public money.

These regulations are totally disproportionate to what they are trying to regulate in the interests of patients. The best thing the Government can do is graciously to withdraw the regulations, think about what is going to happen tomorrow, reflect on this and, after further consultation with stakeholders, come back with regulations which live up to the promises that the Government made and are more appropriate for the organisations being regulated.

[Baroness Jolly]

My Lords, just under a year ago on 8 March 2012 we were asked, during the passage of the Health and Social Care Act, to accept a last-minute change of structure of local Healthwatch because, as the Minister put it at the time, on reflection the Government realised that greater flexibility was needed over the organisational form of local Healthwatch. It was not entirely clear what lay behind this sudden realisation, which happened after the Bill had been through the Commons. The House was given only five working days within which to make sense of 50-plus government amendments that were put down at the time to achieve this change.

This was a very unusual action for the Government to have taken and very little explanation was given. Stakeholders in patient and public engagement were not consulted; we were asked, effectively, to give the Government the benefit of the doubt. We continued to put our faith in the Government’s intention as stated in the White Paper, Equity and Excellence, which aimed to strengthen the collective voice of patients through a new independent consumer champion within the Care Quality Commission, manifested at a local level as local Healthwatch with a strong local infrastructure.

During the debate on Report, the Minister described Healthwatch as, indeed, the voice of the people. At that time, we were dealing with the third reform of the way in which local communities influenced their NHS in three years, and there was a general view that, for their sake, we needed to get on with it. To avoid switching off the power for local communities to have a say in local services for too long, we felt the turbulence of further reform needed to be kept to a minimum. We hoped that secondary legislation would give the system its real shape and we would have an opportunity to ensure that the essentials were in place, changes in structure notwithstanding. This secondary legislation, which is among the most difficult to fathom, really fails to reassure.

My noble friend Lady Cumberlege will deal with freedom of speech and action. I would like to ask my noble friend the Minister about two issues relating to who will make local Healthwatch’s decisions on what it does and how it does it, and what type of involvement lay people or volunteers will have in those decisions.

Local Healthwatch must be a social enterprise contracted by a local authority and may have many subcontracts with other organisations—which may or may not be local or social enterprises—to support or carry out its statutory functions. To try to cut through this structural tangle and preserve the essence of local Healthwatch as the Minister intended it to be—the “collective voice of patients” operating through a “strong local infrastructure”—in March 2012 we focused on who would be involved. We debated the independence of local Healthwatch from the local authority that contracts it, and similarly the independence of Healthwatch England from the CQC, of which it is a committee.

We felt that if local people wholly outside the health and social care system were leading this new structure, they would make it work properly, despite any inherent inadequacies which we were not afforded the time to correct. Therefore, we were pleased when on Report the Minister gave a clear and unambiguous undertaking on behalf of the Secretary of State. She said:

“I have listened to the concerns expressed about the need for local healthwatch to have strong lay involvement. I completely agree. This will be vital to the success of local healthwatch. Therefore, I confirm to the House today that we will use the power of the Secretary of State to specify criteria, which local healthwatch must satisfy, to include strong involvement by volunteers and lay members, including in its governance and leadership. This will have the effect that a local authority cannot award a local healthwatch contract to a social enterprise unless this condition is satisfied. I hope that that provides reassurance to noble Lords”.—[Official Report, 8/3/12; col. 1990.]

Despite the evident good intentions behind this undertaking, something seems to have gone wrong with its execution. There is a serious legal contortion in the regulations around the definition of “lay persons and volunteers”. Suffice to say, it can include staff of health and social care commissioners or providers, as long as they are not clinicians.

This brings me to the role of the Secondary Legislation Scrutiny Committee of your Lordships’ House. It considered this SI on 15 January and its 23rd report draws these regulations to the specific attention of the House,

“on the grounds they give rise to issues of public policy likely to be of interest to the House and that they may imperfectly achieve their policy objective”.

The committee noted that staff could be decision-makers in local Healthwatch. The department did not dispute this in its response to the committee, which therefore concluded that,

“the current wording may leave Local Healthwatch vulnerable to manipulation”.

The committee has been unequivocal in highlighting the errors it perceives in the secondary legislation, saying:

“The Department has offered a legal and policy response, but that may not be enough: the Department needs to address urgently the points raised to the satisfaction of the public because without trust in the basic structure the Department simply may not get the volunteers it wants”.

These regulations do not deliver on the undertaking we were given. There is no assurance of independence, credibility or a strong collective voice for patients. Local Healthwatch could be a mere proxy voice spoken by others—indeed, those others are the very people against whom that voice may wish to speak.

To help reassure both this House and the committee, perhaps the Minister could help me with two scenarios. First, could the manager of a care home sit on its local Healthwatch? If he or she did so, how confident would local people be in the conclusions of that local Healthwatch about the quality of services both at that care home and others? Secondly, could a local profit-making provider of primary care be a local Healthwatch contractor? If so, could its manager sit on the local Healthwatch decision-making group? How confident would local people be in the information they obtained from local Healthwatch in helping them choose a GP?

Moving on, what exactly constitutes “involvement”? The regulations require,

“a procedure for involving lay persons or volunteers”,

although the distinction is unclear. As the Secondary Legislation Scrutiny Committee points out, “involvement” is not defined. The main problem is that in paragraph 38 the regulations deliver,

“the involvement of lay persons and volunteers in the governance”,

but not participation in decision-making, which one would have expected to see in Regulation 40(4).

We know from Sections 23 and 26 of the Health and Social Care Act, which relate to the national Commissioning Board and CCGs, that involvement in the context of patient and public involvement may simply mean giving information. There are no criteria for when more is required.

Social Care: Funding

Baroness Jolly Excerpts

Monday 21st January 2013 Lords Chamber

[Earl Howe]

My Lords, we have to speak speculatively and hypothetically because I cannot give the noble Baroness any indication of the level at which the Government will finally propose to set the cap. The level of the cap needs to represent an affordable and sustainable relationship between the state and the individual. We will give due regard to the Dilnot recommendations for the cap while taking into account current economic circumstances. We will set out further details in the coming weeks but I am sure that the point that the noble Baroness effectively makes will be closely borne in mind as we approach decision time.

[Baroness Jolly]

My Lords, with more people needing social care, and with a higher cap than anticipated under Dilnot being probable, what provisions are being made to assist local authorities to cope with managing deferred payments for care?

NHS: Clinical Commissioning Groups

Baroness Jolly Excerpts

Wednesday 16th January 2013 Lords Chamber

[Earl Howe]

My Lords, that is a very important principle. It is one of the reasons why we felt that the NHS Commissioning Board should be responsible for the allocation of resources to CCGs and not Ministers, to avoid any perception of party-political interference. However, the Government’s mandate to the board makes clear that we would expect the board to place equal access for equal need at the heart of its approach to allocations. That is why ACRA has been charged with developing formulae independently to support the decision that the board takes.

[Baroness Jolly]

My Lords, the first rule of funding is that recipients are never happy with their allocation. Given that, will the Minister assure the House that, with new configurations that we have with public health and CCGs, the model used will regularly be reviewed to ensure that it remains fit for purpose?

[Earl Howe]

Yes, my Lords. As I have indicated, as regards the NHS allocations, the board is clear that the model needs to be reviewed. That does not necessarily mean that it will need to change; the board will have to keep an open mind about that. Clearly, the board was not happy that the formula as currently constructed best met future needs. As regards public health, I think that we are in a better place. As my noble friend will know, the allocations were announced recently and they provide for considerable real-terms increases everywhere around the country.